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Tuberculosis in Santa Clara County

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									Tuberculosis in Santa
 Clara County 2008

             September 24, 2008
           Julie Higashi, MD PhD
Tuberculosis Prevention and Control Program
Santa Clara County Public Health Department
TB in the news
TB Case Rates,* United States, 2007



                                                 D.C.




                      < 3.5 (year 2000 target)
                      3.6–4.4
                      > 4.4 (national average)
*Cases per 100,000.
                                          Tuberculosis case rates
                                16

                                14     13.4
  Rate per 100,000 population




                                12

                                10

                                 8                   7.2
                                                                     6.0
                                 6
                                                                                    4.4
                                 4

                                 2
                                                                                                    1.0
                                 0
                                     SCC 2007   California 2007 California 2004 United States   National 2010
                                                                  Objective         2007          Objective



Sources: SCC Department of Public Health, CDPH, CDC, WHO
Note: Global TB case rate was 136 per 100,000 in 2006
 TB case rates by reporting jurisdictions in
              California, 2007
                                20
                                       17.7                                                                       Santa Clara County had
                                18
 Rate per 100,000 population




                                                   16.6                                                           the third highest TB case
                                16                                                                                rate in the California
                                                            13.4
                                14
                                                                       11.9
                                12                                               10.5
                                10                                                           9.0      8.4     7.9        7.4                7.2
                                 8                                                                                                 7.0
                                 6
                                 4
                                 2
                                 0
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                                                                           Reporting Jurisdictions
Source: California Department of Health Services, California Department of Public Health, Division of Communicable
    Diseases, TB Control Branch, 2007. California Department of Finance, Demographic Research Unit
           TB cases by select California counties,
                           2007
      1000
                                                                           Santa Clara County (SCC)
                  818                                                      had the third highest TB
           800                                                             case count in the California


           600
TB cases




           400
                              280
                                             241           217
           200                                                            149            143
                                                                                                         110

             0
                   Los     San Diego Santa Clara         Orange        Alameda          San    Sacramento
                 Angeles                                                             Francisco
                                                      Counties

 Source: California Department of Health Services, California Department of Public Health, Division of
     Communicable Diseases, TB control Branch, 2007
       San Jose = 167 cases




5/23
                        TB cases by U.S. and foreign born,
                                   2002-2007
                                             U.S. born       Foreign born    Unknown
                  300

                  250
Number of cases




                  200

                  150     237
                         (92% )      209                                          202            217
                                                     184             175         (89% )         (90% )
                                    (92% )
                  100                               (91% )          (88% )


                   50

                          20          15             18               22           23            18
                    0
                         2002       2003           2004             2005         2006           2007
                                                         Year reported


        Source: SCC Public Health Department, Epidemiology & Data Management, TB Records, 2002-2007
           TB cases by race/ethnicity, 2007

                                      White (4%)
                                                          Hispanic (17%)

     N = 241
                                           9
                                                     40
                                                                         Black (4%)
                                                                10
                                                                     2     Native
                                                                           Hawaiian (1%)

                                     175
 Asian/Pacific
 Islander (73%)




Source: SCC Public Health Department, Epidemiology and Data Management , TB Records, 2007
Note: Missing or unknown race/ethnicity for 5 TB cases
SCC population is ~ 26% API, 24% Hispanic, 44% white (DOF, 2000 US Census)
    TB cases by foreign country of origin

                          Other* (11%)

         Ethiopia (2%)
         Peru (2%)                     23                        Vietnam (29%)
                              5
                          5                            62
   China (7%)
                        15
                                                                                     N = 217
Mexico (11%)
                        23


                                  32                51
                                                                Philippines (24%)
          India (15%)



Source: SCC Public Health Department, Epidemiology and Data Management , TB Records, 2007
* ‘Other’ category includes countries with fewer than 5 TB cases
                       TB cases by age, 2007
                                         0-14 years

               65+                                             15-24 years
               years                        10
                                           (4% )
                                                   27 (11% )                          N = 241
                       64 (27% )




                                                          68 (28% )
                                                                       25-44
                                                                       years
                             72 (30% )
            45-64
            years



Source: SCC Public Health Department, Epidemiology and Data Management , TB Records, 2007
                    Primary Anti-TB Drug Resistance
                        United States, 1993–2007*
          10
% Resistant




              5



              0
                  1993      1995         1997         1999        2001         2003          2005   2007
                                                 Isoniazid            MDR TB

                     *Updated as of April 23, 2008.

                     Note: Based on initial isolates from persons with no prior history of TB.
                     Multidrug resistant TB (MDR TB) is defined as resistance to at least
                     isoniazid and rifampin.
      TB cases with initial drug susceptibility
     test by resistance to isoniazid (INH), 2007
                                                      N = 241
Cases with
positive culture
but without                                                                                         INH
susceptibility                                                                                      susceptible
status (n=13)                                                                                       (158)

                   5.4%                              Cases with
                                                     positive culture
                                                     and INH                            86%
  Cases                                              susceptibility
  without                             75.9%
               18.7%                                 status (183)
  positive
  culture
  (n=45)                                                                          14%


                                                                           INH resistant (25)




     Source: SCC Public Health Department, Epidemiology and Data Management , Tuberculosis Records, 2007
                      TB case rates and counts in SCC,
                                 1998-2007
                                       TB case count              TB case rate
                300                               15.0                                            16
                      14.8
                             14.0   13.8                                                 13.4
                                                         13.1                                     14
                                                                                 12.8




                                                                                                       Rate per 100,000 population
                250                        12.5
                                                                  11.6   11.4                     12
                200
TB case count




                                                                                                  10

                150                                                                               8

                                                                                                  6
                100
                                                                                                  4
                 50
                                                                                                  2

                  0                                                                               0
                      1998   1999   2000 2001     2002 2003       2004   2005 2006       2007
                                                  Year reported
 Source: SCC Public Health Department, Tuberculosis Records, 1998-2007. California Department of Finance,
     Demographic Research Unit
                         Number of Tuberculosis Cases and Case Rates
                            in Four Bay Area Counties* 1998-2007
Number of Tuberculosis

                         800                                                     18




                                                                                      Cases per 100,000
                         700                                                     16




                                                                                         population
       Cases




                         600                                                     14

                         500                                                     12

                         400                                                     10
                              98

                              99

                              00

                              01

                              02

                              03

                              04

                              05

                              06

                              07
                           19

                           19

                           20

                           20

                           20

                           20

                           20

                           20

                           20

                           20
                                       Number of Cases        Case Rate

         Percent change in Bay Area county case count: 1998-2007: -3.8%
         Chi-square test for trend:
         1998-2003: significant downward trend (p<0.0001)
         2004-2007: significant upward trend (p=0.027)
                                                                                               15
                               *Alameda, San Francisco, San Mateo, Santa Clara
    Why is TB on the rise in Santa
           Clara County?
   Not definitive, but the data suggests:
     Increases in population of the county
     Shifts in the demographics of our county
     May be related to migratory movement of specific
      populations
   No indication that we are in the middle of an
    epidemic or outbreak
   Pediatric cases are stable
         Protecting HCW from TB




mcaaron.wordpress.com/2008/07/05/sneezing/
      TB is transmitted via aerosol




pathport.vbi.vt.edu/.../Tuberculosis_2.html
Infection Control c 1926
           Infection Control 2008




   Negative Pressure Isolation Rooms
   UV lamps
               HCW exposures
   Patient codes, need to resuscitate and intubate.
   Interview patient outside of house after a fall.
   Transportation of patient to hospital.
     Pt is coughing
     Pt is not coughing
     HCW known exposure to TB
   Patient codes, need to resuscitate and intubate.
    (High)
   Interview patient outside of house after a fall.
    (Low)
   Transportation of patient to hospital.
     Pt is coughing (med-high)
     Pt is not coughing (low-med)
Transporting Infectious Patients


                    Patient should be
                     wearing surgical mask
                    Windows of vehicle
                     should be open
                    All other passengers
                     should be wearing N95
                     mask.
                    Rules of thumb
   Pts whose sputa were initially smear positive reduce
    their infectious burden by one log, i.e. 1/10 the original
    burden, after 2 wks of effective anti-TB meds.
       Can be released from home isolation once no longer smear
        positive.
   Pts whose sputa were initially smear negative have
    about 1/5 the infectious burden of smear positive pts.
       Can be released from home isolation after 4 days of anti-TB
        meds.
Annual TST and TB screening
                Establish baseline on hire
                If employee converts from
                 negative to positive
                    Assess for active TB
                    If not active TB, can provide
                     treatment for latent infection
                If employee is positive
                    Other diagnostic tests available
                     (interferon gamma release
                     assays)
                    Symptom review and CXR on
                     hire
                    Symptom review annually
                    CXR if symptomatic and q 4
                     yrs if asymptomatic
              Acknowledgements
   Santa Clara TB Prevention and Control Program
       Cynthia Haines, RN - Program Manager
   David Hill, MPH, PhD - Communicable Disease
    Epidemiologist, Santa Clara County PHD
                       Questions?
   Santa Clara County TB Prevention and Control
    Program
       408 885 4214

								
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